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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> __ - (Complete in Triplicate) Permit No. <br /> ...... ............ ............ ............. .... <br /> ------.___.--.____.______________________________ This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/L N :rl ._ .. �� <br /> =�.,o�'.r. - - CENSUS TRACT <br /> Owner's Name ------- --- ----- - ------- - - - -------- - ...Phone ------- ---- •---------................. <br /> 6 .._ --ems <br /> Address city e --'G------- -----------------------•-- <br /> Contractor's Name �L)1-<.! :.... ' ...... ---- ---------------- --- <br /> A <br /> Installation will serve Residence Apartment-House�❑ Commercial:❑Trailer-Court- ❑ - <br /> Motel ❑Other------ .. .......------- --• ...... <br /> Number of living units:...---- __- Number of bedrooms -__-....Garbage Grinder ............ Lot Size .... ----- <br /> Water Supply: Public System and name ----•-------------------------------------------- ----------------•---------------_-------- '--•----•------Private �. <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ _Peat❑ Sandy Loam 2( Clay Loam ❑ <br /> Hardpan ❑ Adobe❑ Fill Material -------------- If yes,type-_--._-.-------------------- <br /> t <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: INo septic tank or seepage pit permitted if public sewer is available within 200 feet,J <br /> PACKAGE TREATMENT ( ] SEPTIC TANK:[ Size---- ........................................... Liquid Depth ...............__-_-_.----. <br /> Capacity --------- ---- Type------------------- Material_'_----------------- No. Compartments --.................... {� <br /> Distance to nearest. Well _________-----------_--------------.Foundation ...__-_-...._--_-..__ Prop. Line ........... <br /> LEACHING LINE ( ] No. of lines .. Length of each-lin—e _------------ - ------ Total Length ............................ <br /> 'D' Box ------------ Type Filter Materia( _.------ ______----Depth Filter Material _-...--_-_--_._...-----------_...._......... <br /> 3 I <br /> Distance to nearest: Well ............ -Foundation ........................ Property Line ___._-___--_--__._._-._- <br /> SEEPAGE PIT [ ] Depth .................... Diameter _............... Number _ ___ . Rock Filled Yes ❑ No .C3 <br /> Wafter Table Depth ---...------•-•------•--------------- ...~Rock Size <br /> Distance to nearest: Well ------------- ..........................Foundation .--.--.--.._-_-_-. Prop. Line .................... <br /> t t <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------.----------------------------------- Date __-_--_____.---___.-__._.._--.._._} <br /> Septic Tank (Specify Requirements) . -` <br /> �rsposal Field <br /> (Specify Requirements) s., _ . ._. _ I --•-- <br /> - ------ --- ----- - -. .. ._.. ,3. . � <br /> . ._.... ----------------------------•---- -- ---------------- ----- ---- ------------------ <br /> - - ---- ---- --- ----- <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall net employ any person in such manner <br /> as to become subject to Workman's Cornpensati0 ws of California." <br /> Signed ...................... .... Owner <br /> By . ......... -- - Title <br /> - -- .-.---.- _----- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- _. .............. DATE - -"7. --_.___..__....._ <br /> BUILDINGPERMIT ISSUED ..... ................................................ .......................................-----..DATE ----•------------............--- ......... <br /> ADDITIONALCOMMENTS -----------------------................................................ ............................................................._v. _.. ._.... <br /> - _ <br /> _. ---•-• -•-----•-- -- ..-. ._..-...-• ----•------------------- <br /> .. <br /> Final Inspection by: --•- --------- -_---------_ --------------------------------- --------Date �" �. .70 ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> E. H. 9 1-'b8 Rev. SM <br />